Availability of the certification program support offered is for Kaiser Permanente nurses on a first-come-first-served basis. Your NUID is required to complete the form. Submitting this form will start a validation process to determine your eligibility. Submission of this form does not guarantee approval. You may be contacted for additional information.Registration InformationName* First Last NUID*Email*Provide the email address you will be using to register with the credentialing organization. Contact InformationCell Phone Number*Home Phone NumberOffice Phone NumberPersonal Email KP Email Degree InformationWhat is your highest degree in Nursing?*Hospital DiplomaAssociate DegreeBachelor's DegreeMaster's DegreePhD in NursingDoctor of Nursing PracticeDoctor of Nursing ScienceDo you have a degree in an area other than Nursing that is higher than your Nursing degree?*YesNoWhat is your highest Non-nursing degree?*Hospital DiplomaAssociate DegreeBachelor's DegreeMaster's DegreeDoctorate DegreePlease spell out your degree and area of study*E.g. Bachelor of Arts in PsychologyCertification Program InformationIdentify the certification program you are interested in*These certification paths take focused time and effort. For that reason you can only apply for support for one certification program at a time.AACN - CCRN (Adult) Acute/Critical Care NursingAACN - CCRN (Neonatal) Acute/Critical Care NursingAACN - CCRN (Pediatric) Acute/Critical Care NursingAACN - CCRN-E (Adult) TeleICU Acute/Critical Care NursingAACN - CCRN-K (Adult) Acute/Critical Care Knowledge ProfessionalAACN - CCRN-K (Neonatal) Acute/Critical Care Knowledge ProfessionalAACN - CCRN-K (Pediatric) Acute/Critical Care Knowledge ProfessionalAACN - PCCN (Adult) Progressive Care NursingAACN - PCCN-K (Adult) Progressive Care Knowledge ProfessionalANCC - AGACNP-BC Adult-Gerontology Acute Care Nurse Practitioner CertificationANCC - AGCNS-BC Adult-Gerontology Clinical Nurse Specialist CertificationANCC - AGPCNP-BC Adult-Gerontology Primary Care Nurse Practitioner CertificationANCC - FNP-BC Family Nurse Practitioner CertificationANCC - NE-BC Nurse Executive CertificationANCC - NEA-BC Nurse Executive, Advanced CertificationANCC - NHDP-BC National Healthcare Disaster CertificationANCC - NPD-BC Nursing Professional Development CertificationANCC - PMHNP-BC Psychiatric-Mental Health Nurse Practitioner (Across the Lifespan) CertificationANCC - RN-BC Ambulatory Care Nursing CertificationANCC - RN-BC Cardiac Vascular Nursing CertficationANCC - RN-BC Gerontological Nursing CertficationANCC - RN-BC Informatics Nursing CertficationANCC - RN-BC Medical-Surgical Nursing CertficationANCC - RN-BC Nursing Case Management CertificationANCC - RN-BC Pain Management Nursing CertifcationANCC - RN-BC Pediatric Nursing CertificationANCC - RN-BC Psychatric-Mental Health Nursing CertificationCCI - CNOR Certified Perioperative NurseIs this request for initial certification or for re-certification?*Indicate whether you are seeking this certification for the first time, or are already certified and are looking to get re-certified.Initial CertificationRe-CertificationProgram Attestation*Terms and conditions: • I confirm that I meet the eligibility requirements of the selected certification and am ready to sit for the exam. • I confirm that the certification selected is relevant to my nursing practice. • I agree to APPLY for the certification exam within 30 days of receiving approval. • I agree to sit for the exam within 90 days of APPLICATION APPROVAL or within the timeframe specified by the credentialing organization. I agree to the terms and conditions of the programRelease of Information Consent*In exchange for the support for the selected certification program Kaiser Permanente will be provided periodic updates on the status of your progress by the credentialing organization. You are hereby authorizing the credentialing organization to share the date you become certified with Kaiser Permanente. I authorize the credentialing organization to share the date I become certified with Kaiser PermanenteCommentsThis field is for validation purposes and should be left unchanged.